-Objective: To evaluate the diagnostic usefulness of cerebral spinal fluid (CSF) cellularity, protein, neutrophils, glucose and lactate for detection of postoperative bacterial meningitis. Method: This p rospective study was conducted in 28 postoperative neuro s u rgical patients from 2002 to 2005 at University of São Paulo. The CSF markers were plotted in a receiver operating characteristic (ROC) curve to evaluate their accuracy. Results: Based on the area under ROC curve CSF glucose, cellularity, and lactate were cons i d e red good tests. Polymorphonuclear and protein did not achieve enough accuracy to be used clinicall y. Conclusion: The CSF glucose, lactate, and cellularity can be used for the diagnosis of bacterial meningitis. Moreover, it can be helpful to differentiate bacterial from aseptic meningitis.KEY WORDS: CSF, bacterial meningitis, neurosurgery, ROC analysis, postoperative infection. Baseadas na área sob a curva ROC, glicorraquia, celularidade e concentração de lactato foram considerados bons testes. A contagem de polimorf o n u c l e a res e a pro t e í n o rraquia não atingiram acurácia suficiente para serem utilizadas clinicamente. Conclusão: A glicorraquia, a concentração de lactato e a celularidade podem ser utilizadas clinicamente para o diagnóstico da meningite bacteriana. Esses marc a d o res também podem ser úteis na diferenciação entre meningite bacteriana e asséptica. PALAVRAS-CHAVE: meningite bacteriana, LCR, neurocirurgia, curva ROC, infecção pós-operatória.

Sodium disorders are the most common and most poorly understood electrolyte disorders in neurological patients. The aim of this study was to determine the incidence of sodium disorders and its association with different traumatic brain injuries. This prospective study was conducted in 80 patients diagnosed with moderate and severe traumatic brain injuries. All patients underwent cerebral computed tomography. Incidence of sodium disorders, presence of injuries in the first computed tomography after traumatic brain injury, and level of consciousness were analyzed. Patients that presented other potential causes of sodium disorders and systemic trauma were excluded from the study. The incidence of sodium disturbances was 45%: 20 patients presented hypernatremia and 16 hyponatremia. Refers to all patients with sodium disturbances 53% were detected in the first sample. We recorded at least one measurement <125 mEq/L in 50% of the patients with hyponatremia. A greater incidence of sodium disorders was found in patients with subdural, intracerebral hematoma and with diffuse axonal injury. The incidence of sodium disorders among the patients with diffuse lesions was greater than in the group of patients with brain contusion (P = 0.022). The incidence of sodium disorders is higher in patients with diffuse traumatic brain injuries. No association was found between focal lesions and proportion of sodium disorders.

Objectives: To elucidate the impact of early tracheostomy on hospitalization outcomes in patients with traumatic brain injury. Data Sources: Lilacs, PubMed, and Cochrane databases were searched. The close-out date was August 8, 2018. Study Selection: Studies written in English, French, Spanish, or Portuguese with traumatic brain injury as the base trauma, clearly formulated question, patient’s admission assessment, minimum follow-up during hospital stay, and minimum of two in-hospital outcomes were selected. Retrospective studies, prospective analyses, and case series were included. Studies without full reports or abstract, commentaries, editorials, and reviews were excluded. Data Extraction: The study design, year, patient’s demographics, mean time between admission and tracheostomy, neurologic assessment at admission, confirmed ventilator-assisted pneumonia, median ICU stay, median hospital stay, mortality rates, and ICU and hospital costs were extracted. Data Synthesis: A total of 4,219 studies were retrieved and screened. Eight studies were selected for the systematic review; of these, seven were eligible for the meta-analysis. Comparative analyses were performed between the early tracheostomy and late tracheostomy groups. Mean time for early tracheostomy and late tracheostomy procedures was 5.59 days (sd, 0.34 d) and 11.8 days (sd, 0.81 d), respectively. Meta-analysis revealed that early tracheostomy was associated with shorter mechanical ventilation duration (–4.15 [95% CI, –6.30 to –1.99]) as well as ICU (–5.87 d [95% CI, –8.74 to –3.00 d]) and hospital (–6.68 d [95% CI, –8.03 to –5.32 d]) stay durations when compared with late tracheostomy. Early tracheostomy presented less risk difference for ventilator-associated pneumonia (risk difference, 0.78; 95% CI, 0.70–0.88). No statistical difference in mortality was found between the groups. Conclusions: The findings from this meta-analysis suggest that early tracheostomy in severe traumatic brain injury patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient’s early rehabilitation and discharge.

Background:Chordomas are rare tumors that arise from the remnants of embryonic notochord anywhere along the neuroaxis. Even though they may occur in an extraosseous intradural location, the most common sites include the sacrococcygeal and clivus regions. The authors report a unique presentation encompassing the pineal region with metastasis to the peritoneum after a ventriculoperitoneal (VP) shunt procedure and review the current knowledge about their pathophysiology and management. The presentation and clinical history endorse the idea that intradural extraosseous chordomas may be distinct from ecchordosis physaliphora and probably do not derive from it.Case Description:An 18-year-old male with previous history of VP shunt presented to the emergency room with pain and abdominal distension. Computed tomography (CT) scans revealed a mass in the pineal region and in the abdominal cavity. Histopathologic exams showed chordoma in both abdominal and cranial samples. The patient died due to systemic complications.Conclusion:The authors hypothesized that notochord remnants may subsist within the brain and occasionally may generate a neoplastic lesion.

Paraclinoid aneurysms constitute formidable surgical challenge. The complex surgical anatomy and several factors such as size and projection of the lesion, choice of the surgical approach, relationships between the aneurysm and perforator vessels, site of proximal control, and potential improvement or worsening of visual symptoms account for these difficulties. In such complex cases, surgical nuances frequently determine the final outcome. In this paper, the authors present a comprehensive review of the tricky regional anatomy and describe the operative nuances one of the senior authors (E. dO.) has used to operate on these complex lesions.

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This study examined a rectifying technique for correcting geometric distortion encountered in magnetic resonance images related to static field inhomogeneities (resonance offsets), and the technique proved to be highly successful in producing consistently accurate stereotactic target registration. The technique is applicable to all routinely used spin-echo MRI.

Dog bites are increasingly being recognized as posing a major public health problem. In the U.S., Weiss et al. reported a rate of 12.9 per 10,000 persons, for dog-bite related injuries resulting in a total of 333,687 visits to Emergency Departments 1 . Children most commonly fall victim, where the head and neck are the most frequent sites of injury accounting for some 80% of such cases.To date, craniocerebral injury cases caused by dog bites have been little published in the medical literature 2,3 . Two cases of penetrating head injury from dog bites are presented and discussed in the context of the current literature on clinical and radiological evaluation, and treatment. CaseThis study was approved by the commission of ethics of the institution and we obtained the informed consent of the responsible for the patients for publication. Case 1On January, 2006 a previously healthy two-year-old boy was brought to the "Hospital das Clínicas" of São Paulo 12 hours after being attacked by a Rotweiller dog in the head. The boy did not lose consciousness, remained alert and responded appropriately. Examination showed a scalp injury on both sides of the head. The CT scan disclosed a depressed skull fracture in the right temporal bone, where the scalp injury was larger (Fig 1A). The child was submitted to surgery with a large incision. There were five depressed skull fractures in the temporal and parietal bones, not directly under the scalp injury itself, which were repaired with a wide craniotomy. The next day the child presented CSF leakage on the left side from the scalp injury, and underwent surgery for a second time. The second CT scan showed a skull fracture in the left temporal bone, not revealed in the first CT scan (Fig 1B). Surgery was carried out on this side and two depressed skull fractures were found not under the scalp wound, but some distance away (Fig 1C, 1D). A large craniotomy was performed and the dural laceration was treated. The boy received a wide spectrum prophylactic antibiotic (oxacilin, ceftriaxone and metronidazol) for 14 days, anti-rabies and anti-tetanus vaccines, rabies immunoglobulin, where treatment was complemented with psychological therapy. At a twelve month-follow-up, the boy was normal without any handicap. Case 2On May, 2006 a previously healthy three-year-old girl was brought to the "Hospital das Clínicas" of São Paulo 10 hours after she had been attacked to the head by a pitbull dog. She did not lose consciousness and presented scalp injuries on both sides of the head as well as to the posterior region of the head. The girl was conscious and responded appropriately. The CT scan showed a complex depressed skull fracture in the left temporal bone; two depressed skull fractures in the occipital bone and signs of pneumocephalus. The 3D CT showed both bone and brain injuries (Fig 2). The girl was submitted to surgery with wide exposure of the lesions. Fractures and dural lacerations were corrected and (Figs 3 and 4). After surgical treatment she received prophylactic antibiotics (oxacili...